ObjectiveTo assess the safety and efficacy of upper eyelid gold weight implants in managing paralytic lagophthalmos and to compare two surgical techniques for their insertion.Study DesignRetrospective case series.SettingTertiary referral center.PatientsOne hundred four patients had a gold weight implanted for paralytic lagophthalmos between 1982 and 1996 at the Royal Prince Alfred Hospital in Sydney. Each patient had more than 2 years of follow-up of lid load function.Main Outcome MeasuresThe effectiveness of gold weights in reanimating eyelid closure, mean duration of gold weight retention, reasons for removal, and complications resulting from a gold weight; these outcomes were also compared using two surgical techniques for gold weight insertion.ResultsOne hundred three patients maintained corneal integrity. At the time of assessment, 46 patients had had their lid loads removed from their eyelids, and 58 lid loads remained in situ. Of the lid loads that were removed, 78% were because the facial nerve had recovered. The remaining 22% were removed because of cosmetic dissatisfaction (7 patients), the lid load becoming too superficial (6 patients), migration (3 patients), partial extrusion (1 patient), and ptosis resulting from too heavy a weight (1 patient).ConclusionGold weights are well tolerated and effective in managing paralytic lagophthalmos. An open surgical technique with direct suture fixation of the gold weight to the tarsal plate produced fewer complications than inserting the lid load into a prefashioned tissue pocket in the preseptal space through a small lateral skin incision.